Characteristics Associated with Substance Use and Non-use Among Street Children in Delhi, India: A Community-based Cross-sectional Epidemiological Study.

Background: Street children are vulnerable to adverse health and risk behaviors and drug use. Substance use among street children has been well documented in several countries. This study reports sociodemographic and peer, family, and stress-related factors associated with substance use and non-use in a representative sample of street children of Delhi. Methods: This cross-sectional survey was conducted through six NGOs working with street children, using Respondent Driven Sampling, in nine districts of Delhi (n = 766, 7-18 years). The multivariable model was developed by applying binary logistic regression analysis. Results: The rate of substance use was 49%. Significant association was found between substance use in the past year and increasing age [Odds Ratio: OR (95% Confidence Interval)] [1.22(1.12,1.33)], male sex [4.34 (2.28,8.26)], lacking psychosocial support from family/relatives [3.27(1.84,5.80)], being engaged in earning from illegal sources, [3.04(1.75,5.29)], family use of substance [2.59(1.38,4.89)], presence of substance-using peers [29.86(14.38,62.01)], lack of non-drug-using peers [2.35(1.46,3.79)], and not possessing basic amenities [2.26(1.31,3.93)]. Conclusion: Multiple modifiable factors exist within the family and peer group, including risk and protective factors or a consequence of substance use. Some challenges in the form of difficulty in reaching out to them and poor treatment seeking by those using substances warrant intensification in both primary and secondary prevention initiatives.

Trazodone for sleep disturbance in opioid dependent patients maintained on buprenorphine: A double blind, placebo-controlled trial.

BACKGROUND: Sleep disturbances are seen even in individuals on opioid agonist treatment (OAT). Established pharmacotherapy for sleep disturbances such as benzodiazepines have misuse potential and increased mortality risk in patients with OAT. No study has explored the role of trazodone on sleep disturbance in individuals maintained on buprenorphine. We aimed to assess the efficacy of trazodone in improving sleep disturbance among individuals maintained on buprenorphine. METHODS: The study was a double-blind, placebo-controlled, parallel, randomised trial. Adult males (18-60 years) stabilised on buprenorphine with Pittsburgh Sleep Quality Index (PSQI) score of above five, without other psychiatric comorbidity were randomised to receive either trazodone (50-150mg per day) or placebo. Sleep-50 questionnaire, Epworth Sleepiness Scale (ESS), Brief Pain Inventory (BPI), Clinical Opiate Withdrawal Scale (COWS), Depression, Anxiety and Stress Scale (DASS)-21, Visual Analogue Scale (VAS) for opioid craving, and PSQI were assessed at baseline and at the end of six weeks. RESULTS: Fifty-one patients were allocated to trazodone arm and 49 to placebo arm. Side-effects of trazodone were minimal and well-tolerated with comparable discontiuation rates between both groups. Significantly greater proportion of patients on trazodone (82%, mean dose 101.9 mg) had PSQI scores five or less than those on placebo (16%) at the end of six weeks. Sleep improvement was in various components like sleep quality, latency, efficiency, and duration of sleep. CONCLUSION: Trazodone is well-tolerated and effective in improving sleep disturbances in individuals with opioid dependence maintained on buprenorphine over a six-week period.

Does Cognitive Therapy Change the Early Maladaptive Schemas in Individuals with Alcohol Dependence? Evidence from a Randomized Controlled Trial.

Background: Although early maladaptive schemas (EMSs) have been suggested as potential vulnerability markers for alcohol dependence (AD), there is less emphasis on addressing these schemas in substance abuse treatment programs. We thus aimed to examine the change in schemas in response to cognitive therapy in individuals with AD. Methods: In this an open-label randomized controlled study, individuals with alcohol dependence syndrome (ADS, n = 84) were randomized to the intervention group (n = 45), which received six cognitive therapy sessions combined with treatment as usual (TAU), or the control group (n = 39), which was on TAU only. Participants were assessed on the measures of EMSs, alcohol use severity, and perceived stress at baseline and posttreatment. Results: The intervention group showed significant improvement in 5 out of 18 EMSs, that is, emotional deprivation, defectiveness, self-sacrifice, unrelenting standard, and negativity, compared to the control group, at the end of the treatment. There was a significant between-group effect for perceived stress but not for alcohol use severity. Conclusion: EMSs can be changed with cognitive therapy in individuals with AD and could be a crucial area to address in treatment programs. Further studies with long-term follow-up are warranted. The trial was registered with the Clinical Trials Registry-India (CTRI/2015/12/006441) on December 17, 2015.

A Prospective Three-Months Naturalistic Follow-Up Study of Outcomes of Patients with Opioid Dependence Discharged on Buprenorphine or Oral Naltrexone.

Background: Comparative studies of the naturalistic course of patients of opioid dependence on naltrexone and buprenorphine are likely to be helpful for clinical decision-making. The article aimed to report on the three-months naturalistic outcomes of patients discharged on naltrexone or buprenorphine from the same center. Methods: Patients with opioid dependence who were discharged on either naltrexone (n = 86) or buprenorphine (n = 30) were followed up for three months for retention in treatment. The patients were also followed up telephonically, and the Maudsley Addiction Profile was applied. Results: The days of retention in treatment were significantly higher in the buprenorphine group (69.5 versus 48.7 days, P = 0.009). Heroin use, pharmaceutical opioid use, injection drug use, involvement in illegal activity, and percentage of contact days in conflict with friends in the last 30 days reduced over three months in both the groups, while the physical and psychological quality of life improved in both the groups. Additionally, in the naltrexone group, smoked tobacco use, cannabis use, and percentage of contact days in conflict with family within the last 30 days reduced at three months compared to baseline. Conclusion: With the possible limitations of choice of medication-assisted treatment for opioid dependence being determined by the patient, and prescribing related factors and sample size constraints, the study suggests that retention outcomes may vary between naltrexone and buprenorphine, though both medications may improve several patient-related parameters. However, a true head-to-head comparison of the outcomes of buprenorphine and naltrexone in a naturalistic setting may be difficult.

Relapse during opioid use disorder treatment: A pilot study to understand the reasons for opioid use during treatment.

Background: Opioid use is a cause of concern in many parts of the world. About 2.1% Indians use opioids. Opioids are also the most common drugs used by injection drug users in India. Despite various treatment strategies used to manage opioid use disorders (OUDs), relapse is common. A good treatment program would make efforts to address lapses and prevent relapse. Hence, there is a need to understand the factors associated with relapse in OUD. Method: One hundred and twenty patients completed a baseline assessment that included socio-demographic details and the Maudsley Addiction Profile (MAP). They were followed up for three months and assessed using telephonic interview for opioid use. All those who relapsed were assessed using the Reasons for Relapse Questionnaire (RRQ). The patients who relapsed were compared with the patients who were abstinent. Relapse was defined as any use of opioid during follow-up. Results: Forty participants relapsed during the 90 days of the study period. Relapsed patients had a greater number of conflict days with family members, used a higher amount of heroin and cannabis at baseline, were less likely to be discharged on buprenorphine, and were more likely to drop out. Participants cited mood and social reasons more often than cue/craving and unwell domains of RRQ. Conclusion: Baseline treatment and prospective factors are associated with relapse in OUD. Addressing these factors can help in reducing relapse in OUD patients.

Reasons for leaving treatment among patients with opioid dependence: A 3-month prospective follow-up study.

OBJECTIVE: This study aimed to ascertain the reasons why patients with opioid dependence leave treatment. DESIGN: Prospective follow-up observational study. SETTING: This study was carried out at a tertiary care substance use treatment facility in north India with both outpatient and inpatient services. The facility is a public-funded institution. PARTICIPANTS: One hundred and twenty opioid-dependent male patients with age 18 years or more who were willing to provide a valid telephone number for followup and willing to consent for the study were included. MAIN OUTCOME MEASURE(S): Enquiries were made using the Reasons to Leave Treatment Questionnaire (RLTQ) and an open-ended question about why the patient left treatment. RESULTS: As per the RLTQ, the most common reasons for patients with opioid dependence leaving treatment were in the domains of external influence, motivational inconsistencies, and problem severity. Logistic problem was another issue that was highlighted by the patients. On open-ended question, the most common reason for leaving treatment pertained to feeling that one has improved and does not need treatment. Baseline characteristics that predicted patients leaving treatment were not being prescribed buprenorphine at discharge, not being formally educated, and living alone or in a nuclear family. CONCLUSION: Several factors may lead to patients with opioid dependence leaving treatment prematurely after receiving inpatient care. Addressing these reasons might help to better retain patients in treatment and improve their outcomes.

Methodological issues in conducting yoga- and meditation-based research: A narrative review and research implications.

Yoga and meditation-based interventions have been extensively utilized in the field of contemporary complementary and alternative medicine for various physical and mental health conditions. Ongoing COVID-19 pandemic has rekindled the interest of researchers in yoga and meditation for its preventive and therapeutic utilities. However, the available literature in this area has several methodological concerns, limiting formers' clinical utility. A comprehensive literature on this topic would stimulate researchers and guide them to conduct research on this topic with robust methodologies. The current review highlights the methodological issues with the yoga and meditation-based Research (henceforth, MBR), discusses some of the contentious issues, and provides future directions. The PubMed, Medline, and google scholar databases were searched to screen records dealing with the methodological issues on MBR. The search yielded 299 records, upon screening, only 24 articles were found suitable for the current study. Common methodological issues with MBR: lack of the consensus definitions of the yoga and meditations, interventions lacking theoretical framework of meditation; inadequate description of the study design; difficulty with participants recruitment, setting up the control groups, and blinding; difficulty in assessing the baseline characteristics of the participants, and validity issues with the outcome measures. A few research, however, have also highlighted the potential measures to overcome these methodological challenges. Yoga and meditation-based interventions are promising for several health conditions. However, literature suffers from considerable methodological issues, thus, limiting its utility in modern clinical practice. The study findings can stimulate and guide future research on this topic.

Teen Addiction Severity Index (T-ASI): Hindi Translation and Validation for Use in India.

Background: Substance use among adolescents is increasing rapidly and becoming a global health concern worldwide. Because of the changing trends and rising magnitude in India, there is an urgent need to adapt and validate instruments to assess adolescents' substance use. The study translated the Teen-Addiction Severity Index (T-ASI) into Hindi and assessed the psychometric properties. Methods: The instrument (T-ASI) was translated from English to Hindi using: (a) forward translation: translation from the source language into the target one, (b) comparison and synthesis of the two translated versions, (c) blind backward translation, (d) comparison of the two back-translated versions and development of prefinal version, (e) conceptual evaluation of items and pilot study, and (f) assessing the psychometric properties. Results: The content validity of Hindi T-ASI was quite high (0.97). A significant positive correlation r = 0.439* (0.014) between the T-ASI family functioning domain and the organization scale of the Family Environment Scale (FES) demonstrated good concurrent validity. Youth self-report substance use domain correlated well with youth self-report behavior problems scale r = 0.385 (0.033) and the psychiatric status domain correlated with all three internalizing 0.606 (<0.001), externalizing 0.363 (0.045), and behavior problem scale 0.546** (0.001). Construct validity showed significant differences between two groups (substance-using and nonsubstance-using groups) in all domains except school and peer status. Cross-cultural validity shows that the two versions are equivalent. The translated version showed satisfactory reliability (Cronbach's α = 0.727). Conclusion: The translation and validation of Hindi-T-ASI show adequate psychometric properties and can be recommended for use in treatment settings across the country.

The Extent of Endorsement of Distal to Proximal Dysfunctional Cognitions in Individuals with Alcohol Dependence: A Comparative Cross-Sectional Study in the Indian Context.

Background: Dysfunctional basic cognitions have been suggested as potential vulnerability markers for alcohol dependence (AD). Although there is a growing body of research on the role of distal cognitive vulnerability factors such as early maladaptive schema in the development of AD, little is known about the role of proximal cognitive factors such as cognitive distortions, dysfunctional attitude, and negative automatic thoughts. Methods: This comparative cross-sectional study aimed to examine dysfunctional cognitions in individuals with AD (n = 84) in comparison with healthy individuals (n = 60). The dysfunctional cognitions were assessed on the Young Schema Questionnaire third version of Short Form, Cognitive Distortion Scale, Dysfunctional Attitude Scale-Form A, and Automatic Thought Questionnaire. Multivariate analysis of covariance was conducted to analyze the group differences in dysfunctional cognitions. Results: After controlling for the group difference in employment status, 12 of 18 schemas were more prevalent in individuals with AD than in healthy individuals. Individuals with AD also scored higher on seven of 10 cognitive distortions, as well as in terms of dysfunctional attitude and negative automatic thoughts. Conclusion: Dysfunctional cognition may play a significant role in developing AD. The findings may enhance our understanding of the nature and severity of dysfunctional cognitions in the development of AD. The information may further assist the clinicians in implementing adequate intervention strategies to manage dysfunctional cognitions in individuals with AD.

Improving Treatment of Substance Use Disorders through Community Drug Treatment Clinics: An Experiential Account.

India has a huge burden of substance use disorder (SUD). The national response to the problem of SUD has been to support addiction treatment centers either in government hospitals or in nongovernmental settings. The existing number of addiction treatment facilities is less compared to the burden of substance use in India. The existing models of treatment in India place undue emphasis on inpatient treatment of SUD. Community-based treatment aims to bring the treatment of SUD closer to the patients in their community. Community-based treatment of SUD utilizes existing services available in the community by establishing an integrated network of community-based services. There have been different models of community-based care for the management of SUD in India. Most of them, however, address short-term withdrawals and do not provide long-term treatment in community. National Drug Dependence Treatment Centre, AIIMS, New Delhi, has been providing community-based treatment for SUD since the 1990s. Two of the three community drug treatment clinics (CDTCs) are in operation for more than 5 years now and cater to the population residing within a defined catchment area. The CDTCs use infrastructure available in the community to operate the clinics. The clinics are run daily by a team of nursing staff, while the doctor is available only twice a week. A menu of options, ranging from short-term treatment to long-term agonist maintenance treatment is provided in the clinic. Both pharmacotherapy and psychosocial interventions are provided. Each clinic caters to hundreds of patients through these facilities. There is a need to expand CDTCs in India considering their cost-effectiveness, acceptability, and overall effectiveness, especially in urban colonies with higher substance-related problems.

Substance use and its associated factors among school students.

Background: . There is lack of comprehensive data on substance use and associated factors among school students in Delhi, India. Methods: . We used a cluster sampling method based on sections of classes in schools to conduct this study in two government-run schools in Delhi. All enrolled students from 8th, 9th and 11th grades participated (n = 405). The WHO Student Drug Use questionnaire was administered in a single session for a class section for assessing substance use. Results: . The participation rate was 90.6%. The rates of past 12 months' use of tobacco, alcohol, cannabis and inhalants were 22%, 12.1%, 12.1% and 8.6%, respectively, while rates for 'sedatives and tranquillizers' were 4.9%, opium 2.7% and other opioids 1.2%. Lifetime use of heroin was reported by two students and use in the past 12 months by one student. Multiple substance use was high. Higher age was associated with the use of alcohol and cannabis. According to logistic regression model results, use by a family member significantly increased the probability of using tobacco (adjusted odds ratio [AOR] 11.3; 95% confidence interval (CI) 3.4-37.8) and alcohol (AOR 3.75; 95% CI 5.1-1059.3). Similarly, use by peers significantly increased the probability of tobacco (AOR 7.7; 95% CI 2.0-29.8) and cannabis use (AOR 5.7; 95% CI 1.5-21.5). Having poor harm perception significantly increased the chances of inhalant use by students (AOR 5.5; 95% CI 1.5-20.1). Conclusion: . The study results bring to attention the prevalent and important problem of substance use among schoolchildren. We recommend that (i) intervention strategies for school settings are important and need to factor in the use of illicit substances (cannabis); (ii) psychosocial intervention by trained school counsellors in school settings is the mainstay for intervention for cannabis and inhalants; and (iii) heroin users should be referred to healthcare facilities for detoxification.

Effectiveness of Interventions Based on Yogic Breathing Practices (IB-YBP) on Substance Use Disorders-A Systematic Review of the Randomized Control Trials and Quasi-Experimental Trials.

INTRODUCTION: Interventions based on Yogic Breathing Practices (IB-YBP) have shown promising results for substance use disorders (SUD). Research in this area is methodologically heterogeneous and only a few, but restricted, systematic reviews are available. The current systematic review aims to assess the effectiveness of IB-YBP for SUD. Materials and Methods: PubMed, Cochrane's Library, EBSCO-Medline, and Google Scholar databases were searched for the randomized- (RCTs) and quasi-randomized trials. Research involving participants with SUD, of either gender or any age, assessing the effectiveness of the IB-YBP either as a standalone intervention or as an adjuvant to standard treatment versus standard pharmacological/non-pharmacological treatment or no-intervention control were included. Studies having participants with co-morbid psychiatric illness and interventions not having IB-YBP as the predominant component were excluded. Results: The initial literature search yielded 396 articles and upon screening, only 14 studies were found eligible for this review. Most studies have researched IB-YBP as an adjunct to the standard treatment for SUD. Evidence for the effectiveness of IB-YBP is mostly available for tobacco and opioid use disorders, though only for short-term outcomes; however, literature is scarce for alcohol- and cocaine-use disorders. This review documented the effectiveness of the IB-YBP for substance use-related outcome parameters such as abstinence, quality of life (QoL), mood, craving, and withdrawal symptoms. Conclusion: IB-YBP may be an effective adjuvant to standard treatment for various SUD. However, more research is required to compare its effectiveness with standard treatment, and assessing its long-term efficacy, for it to be strongly recommended as a treatment strategy.

Co-administration of nalbuphine attenuates the morphine-induced anxiety and dopaminergic alterations in morphine-withdrawn rats.

INTRODUCTION: The classical effects of exogenous opioids, such as morphine, are predominantly mediated through µ-opioid receptors. The chronic use of morphine induces anxiety-like behavior causing functional changes in the mesolimbic dopaminergic system. The mixed µ/κ-agonist, nalbuphine, used either as an analgesic or as an adjuvant with morphine, produces different and opposite effects. However, whether nalbuphine can be used to antagonize morphine-induced anxiety and dopaminergic alterations is not fully known. OBJECTIVE: This study aimed to compare acute and chronic effects of nalbuphine on morphine-induced anxiety and dopaminergic alterations in rats. METHODS: Male adult Wistar albino rats were made opioid-dependent by administering increasing doses of morphine (5-25 mg/kg; i.p.; b.i.d.). Withdrawal was induced by naloxone (1 mg/kg, i.p.), 4 h after the last morphine injection. Anxiety-like behavior was measured using Activity Monitor (Coulbourn Instruments, Inc. USA). Thereafter, the animals were sacrificed and the brain dissected out and the level of cAMP and the transcriptional and translational expression of TH was measured. Nalbuphine was co-administered with morphine, acutely and chronically, at various doses (0.1, 0.3, 1.0, 3.0 mg/kg, i.p.). RESULTS: Morphine-dependent rats showed a significant higher anxiety and cAMP levels and a significant decrease in the expression of TH. Co-administration of chronic doses of nalbuphine attenuates the higher anxiety, cAMP levels, and upregulates the TH expressions; however, the acute nalbuphine treatment does not attenuate the morphine-induced side effects. CONCLUSION: Therefore, nalbuphine might have an important role in attenuating the anxiety and the effects of the dopaminergic pathway and may have potential in the treatment of opioid addiction.

Diversity in substance use behaviour among street children of Delhi under Bayesian paradigm.

BACKGROUND: Shannon's index is one of the measures of biodiversity, which is intended to quantify both richness and evenness of the species/individuals in the ecosystem or community. However, application of Shannon's index in the field of substance use among the street children has not been done till date. METHODS: This paper is concerned with methods of estimating Shannon's diversity index (SDI), which can be used to capture the variation in the population due to certain characteristics. Under the consideration that the probability of abundance, based on certain characteristics in the population, is a random phenomenon, we derive a Bayesian estimate in connection with Shannon's information measure and their properties (mean and variance), by using a probability matching prior, through simulation and compared it with those of the classical estimates of Shannon. The theoretical framework has been applied to the primary survey data of substance use among the street children in Delhi, collected during 2015. The measure of diversity was estimated across different age profiles and districts. RESULTS: The results unrevealing the diversity estimate for street children corresponding to each region of Delhi, under both the classical and Bayesian paradigms. Although the estimates were close to one another, a striking difference was noted in the age profile of children. CONCLUSIONS: The Bayesian methodology provided evidence for a greater likelihood of finding substance-using street children, belonging to the lower age group (7-10, maximum Bayesian entropy-3.73), followed by the middle (11-14) and upper age group (15-18). Moreover, the estimated variance under the Bayesian paradigm was lesser than that of the classical estimate. There is ample scope for further refinement in these estimates, by considering more covariates that may have a possible role in initiating substance use among street children in developing countries like India.

An Observational Study of Serum Brain Derived Neurotrophic Factor Levels in Patients with Alcohol Dependence during Withdrawal.

Brain-Derived Neurotrophic Factor (BDNF) is a neuropeptide that plays an important role in Central Nervous System development, plasticity, learning, and memory. Its role has been explored in alcohol-dependent patients, though the results have been inconclusive. Thus, we aimed to compare serum BDNF levels in alcohol-dependent patients during withdrawal with age and gender matched controls, and assess changes in BDNF levels in the initial abstinence period. BDNF levels of alcohol-dependent patients (n = 25) were compared with controls (n = 25) at baseline. Additionally, BDNF levels were measured in cases on days 5 and 10 of inpatient detoxification. BDNF levels of controls did not differ with cases on day 1, 5, or 10. But BDNF levels increased significantly during alcohol abstinence from baseline to day 10 (Pillai's Trace F = 3.753, p = .039, partial η2 = 0.246), which may suggest its protective role. Thus, serum BDNF values may be potentially used as a biomarker to assess the abstinence state. However, longitudinal studies in different body samples is essential to better understand the role of BDNF in alcohol dependence.

BOLD activation during cue induced craving in adolescent inhalant users.

Inhalants are legally available substances, most of them inexpensive, which are often abused by adolescents. Craving causes their continued use and repeated relapses. There is a need to understand the cue-induced craving and the associated neural mechanisms. In absence of any such prior study, the present study compared the hemodynamic changes in brain associated with craving effect in adolescent inhalant users and healthy controls using blood oxygen level dependent (BOLD) mechanism. This was an observational case control study with twelve adolescents, aged 12-18 years, with current use of inhalants as their primary drug, and twelve healthy, age and gender-matched adolescents, with no lifetime use of inhalants. Clinical assessments included Teen Addiction Severity Index and Visual Analogue Scale for craving. Participants abstained from all substances during 48 h prior to fMRI, confirmed by urinalysis. A validated visual cue block paradigm with neutral and craving cues was presented during the BOLD assessments in a 3 T MR system. The inhalant users exhibited BOLD activation in inferior frontal gyrus, inferior parietal lobule, superior occipital gyrus, cingulate gyrus, lentiform nucleus, thalamus, and culmen as compared to control group. The control group exhibited activation of insula as compared to cases. The results may be attributed to visuo-spatial attention, visual perception, working memory, and motivation associated with visual cue reactivity. This preliminary study provides important findings pertaining to activation patterns in response to cue-induced craving among adolescent inhalant users.

Opioids and sleep - a review of literature.

Sleep is an evolutionarily conserved process and is important for rest and recovery of various biological functions. Sleep and alertness alterations, function as contributing/modulatory factors in initiating and maintaining drug and alcohol abuse and as factors that increase the risk for relapse. Opioid dependent individuals frequently complain of sleep problems during withdrawal and abstinence. Sleep disturbances are seen even among patients on opioid substitution therapy (OST). The aim of this review is to present an overview of sleep problems in opioid dependent patients and to delineate factors associated with sleep disturbance.